Provider Demographics
NPI:1538392832
Name:GRUNDY, BECKY (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:
First Name:BECKY
Middle Name:
Last Name:GRUNDY
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14460 W HONEY LN
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-2314
Mailing Address - Country:US
Mailing Address - Phone:262-653-0850
Mailing Address - Fax:262-653-0853
Practice Address - Street 1:5219 88TH AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-7468
Practice Address - Country:US
Practice Address - Phone:262-653-0850
Practice Address - Fax:262-653-0853
Is Sole Proprietor?:No
Enumeration Date:2009-09-02
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3032-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist